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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 133HOSPITAL LICENSING
SUBCHAPTER KHOSPITAL LEVEL OF CARE DESIGNATIONS FOR MATERNAL CARE
RULE §133.210Survey Team

(a) The survey team composition shall be as follows:

  (1) Level I facilities maternal program staff shall conduct a self-survey, documenting the findings on the approved office survey form. The office may periodically require validation of the survey findings, by an on-site review conducted by department staff.

  (2) Level II facilities shall be surveyed by a team that is multi-disciplinary and includes at a minimum one obstetrics and gynecology physician and one maternal nurse, all approved in advance by the office and currently active in the management of maternal patients at a facility providing the same or a higher level of maternal care.

  (3) Level III facilities shall be surveyed by a team that is multi-disciplinary and includes at a minimum one obstetrics and gynecology physician or maternal fetal medicine physician and one maternal nurse, all approved in advance by the office and currently active in the management of maternal patients at a facility providing the same or a higher level of maternal care. An additional surveyor may be requested by the facility or at the discretion of the office.

  (4) Level IV facilities shall be surveyed by a team that is multi-disciplinary and includes at a minimum one obstetrics and gynecology physician, a maternal fetal medicine physician and one maternal nurse, all approved in advance by the office and currently active in the management of maternal patients at a facility providing the same level of maternal care.

(b) Office-credentialed surveyors must meet the following criteria:

  (1) have at least three years of experience in the care of maternal patients;

  (2) be currently employed and practicing in the coordination of care for maternal patients;

  (3) have direct experience in the preparation for and successful completion of maternal facility verification and/or designation;

  (4) have successfully completed an office-approved maternal facility site surveyor course and be successfully re-credentialed every four years; and

  (5) have current credentials as follows:

    (A) a registered nurse who has successfully completed an office-approved site survey internship; or

    (B) a physician who is board certified in the respective specialty, and has successfully completed an office-approved site survey internship.

(c) All members of the survey team, except department staff, shall come from a Perinatal Care Region outside the facility's location and at least 100 miles from the facility. There shall be no business or patient care relationship or any potential conflict of interest between the surveyor or the surveyor's place of employment and the facility being surveyed.

(d) The survey team shall evaluate the facility's compliance with the designation criteria by:

  (1) reviewing medical records; staff rosters and schedules; documentation of QAPI Program activities, including peer review; the program plan; policies and procedures; and other documents relevant to maternal care;

  (2) reviewing equipment and the physical plant;

  (3) conducting interviews with facility personnel and surveyors may meet privately with individuals or groups of personnel; and

  (4) evaluating appropriate use of telemedicine capabilities where applicable.

(e) All information and materials submitted by a facility to the office under Health and Safety Code, §241.183(d), are subject to confidentiality as articulated in Health and Safety Code, §241.184, Confidentially; Privilege, and are not subject to disclosure under Government Code, Chapter 552, or discovery, subpoena, or other means of legal compulsion for release to any person.


Source Note: The provisions of this §133.210 adopted to be effective March 1, 2018, 43 TexReg 875

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